DO NOT WRITE IN THIS SPACE GENERAL RELEASE FOR …
GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA) 9D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) From: (Include the time period (MM/DD/YYYY) for the treatment by the provider listed in Item 10A) From: To:
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